Provider Demographics
NPI:1548760994
Name:THOMPSON, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 OTIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1221
Mailing Address - Country:US
Mailing Address - Phone:415-557-5720
Mailing Address - Fax:
Practice Address - Street 1:170 OTIS ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1221
Practice Address - Country:US
Practice Address - Phone:415-557-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker